Following NHS England advice on 7 January 2021, and further advice issued 3 February, practices are now guaranteed income protection for the majority of QOF – including eight prescribing indicators for which activity was previously to be recorded. Income protection will be based on historical payments.
The change was part of a new set of measures to free up practices to deliver the Covid vaccination programme.
QOF Expert Dr Gavin Jamie provides an update on how much the key clinical areas for 2020/21 are worth, now that these prescribing indicators have been taken out, and how to go about maximising your income on each.
Most of the QOF has now been suspended for this year. The only indicators that are still active are for flu vaccination and cervical cytology, although these have also had their point score doubled.
For the income protected parts of QOF, NHS England plans to carry practice achievement across from previous years. They have also indicated in their letter of 7 January that the usual prevalence adjustments will be made. Disease prevalence accounts for the biggest variations in income between practices and some simple measures can mean a significant increase in the cash value of QOF to practices.
The below provides some estimates of the values per patient for each area, based on the NHS England indication that prevalence will apply across all points, and that the extra points for flu vaccination/cervical cytology are now necessarily additional rather than recycled – and some tips for how to get the most from these indicators during this busy period.
1. Cervical Screening
Points for both these screening indicators are doubled, meaning cervical screening will likely make a greater contribution to income than usual this year.
It will still depend partly on previous years’ performance – the indicators look back over 3.5 or 5.5 years, so most of the achievement in each is likely to have preceded Covid-19.
Nonetheless, achievement this year will also have effects over the next few years, so it is important to do as much as possible to catch up the Covid-19 backlog.
The indicators start paying at 45% uptake, with top points awarded at the upper threshold of 80%. The points are now awarded differently, however, with women aged 25–49 getting three of the 14 points at 45% and older women getting one of the eight points at the 45% threshold (see below). As with the flu vaccination points, this means practice will be better rewarded this year where they can’t achieve the upper threshold.
| Indicator | Points | Threshold | Points at lower threshold |
| Proportion of eligible women aged 25-49 screened in past 3.5 years | 14 | 45-80% | 3 |
| Proportion of eligible women aged 50-64 screened in past 5.5 years | 8 | 45-80% | 1 |
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2. Coronary heart disease
The CHD area still requires maintenance of the register, and has an active flu indicator which alone is worth about £10 per patient for maximum points.
The flu vaccination indicator for CHD was already the most generous and this year maximum points have been doubled to 14, where 96% of eligible CHD patients have had the jab. There is also a change to how the points are awarded if you don’t meet that top target – in the past practices got no points up to the lower threshold of 56%, after which points were then earned linearly up until 96%. This year, three points are awarded for hitting the lower threshold with additional points awarded on a sliding scale thereafter. This means practices that can’t hit the maximum threshold will be better rewarded this year than usual.
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3. Diabetes
Diabetes also requires practices to maintain the register and has a flu indicator. Overall the total amount a practice can potentially earn from this area will be around £27 per patient.
A summary of what is involved:
Diabetes is an area where it may be more challenging to keep up new diagnoses due to the pandemic – with fewer patients coming in for annual reviews, we’re less likely to pick up on potential new cases. One approach is to call in patients with a record of non-diabetic hyperglycaemia (NDHG) for a blood glucose test. The new indicator to monitor patients who have previously had NDHG has been suspended, but it’s worth checking an HbA1c level in this group annually. Many will have hypertension or another condition that requires annual blood tests anyway – make sure that they also have a diabetes check at the same time.
The flu vaccination indicator is rather less valuable than in CHD, with a potential payment of roughly £2 per patient.
Like all of the flu indicators, the upper payment threshold is high, in this case at 95%, and some exception reporting via the personal care adjustment reporting is inevitable, although this is likely to be simpler this year due to the change in business rule. Patients who expressly decline a flu vaccine should be coded as in the past. Other patients should have their invitations coded, whether this is by SMS message, telephone, letter or verbally. Two coded invitations without a response will automatically except a patient although reminders will remain on the computer system.
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4. COPD
There are only two ‘active’ indicators in COPD, for maintaining the register and flu vaccination, but these are well rewarded. Prevalence is valuable but diagnosis more difficult as some symptoms may be similar to Covid and investigations are potentially hazardous.
Summary of the indicators and points as follows:
There are 8 points for the disease register alone in COPD, the highest in QOF.
The register indicator has been merged with the diagnostic indicator this year, requiring post bronchodilator spirometry for new diagnoses (see separate COPD guide for details). However, spirometry is considered an aerosol generating procedure, so testing is unlikely to happen in the appropriate timescales this year – and, luckily, for technical reasons the business rules do not actually enforce the spirometry requirement.
COPD also has a well-rewarded flu vaccination indicator which is worth up to around £14 per patient, the highest of any area. In this high-risk year, the aim is to hit the targets for all at-risk groups – but if you have to choose, then COPD patients should be your priority.
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5. Stroke
Stroke also has an indicator for flu vaccinations as well as requiring active reporting of the disease register.
The flu indicator is worth four points which works out to around £5 per patient. The rules are the same as the other flu indicators and patients should be invited, vaccinated and have any patient preferences coded in the same way.
Prevalence recording continues to be important. Mostly this will be from patients who have been assessed in secondary care which would normally include a CT scan.
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6. Heart failure
This area now requires practices to report maintenance of the register, although it is advisable to keep up the prescribing indicators where possible.
To qualify for the left ventricular systolic dysfunction (LVSD) part of this QOF area, a patient will need to be coded as having LVSD, with each of the four full words essential to ensure the correct coding for QOF purposes. Echocardiograms may be more difficult to come by this year, but it is worthwhile making sure that previous examinations have been correctly coded – the prescribing indicators are worth up to £80 per patient.
Whilst the prescribing indicators for ACE inhibitors and beta blockers have been suspended this year this remains good practice and will give you a head start on next year’s QOF. The indicators themselves have been changed and slightly simplified (see separate Heart failure guide for details). Both require a relevant prescription from 1 October onwards. In practice, this means that each patient with LVSD should have an annual assessment of their suitability for these treatments. They should then have a prescription or be coded as unsuitable. Many of these assessments could be conducted with the patient by telephone or video call.
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7. Atrial Fibrillation
There is now only one ‘active’ indicator in this area on maintenance of the register. Prevalence is still valuable and making the diagnosis will benefit both patients and the practice income.
Practices will be minimising face-to-face reviews including blood pressure checks, meaning we’re not measuring nearly as many patients’ pulses as usual, so identifying new cases of AF is probably going to be harder this year.
Many of the patients most at risk will have at least a blood pressure reading through the year. Make sure that every visit to the surgery counts and staff know what to do with a patient with an irregular pulse.
The move away from warfarin and towards DOACs has accelerated over this summer, due the reduced need for ongoing monitoring. Only prescriptions after 1 October will count.
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Dr Gavin Jamie is a GP partner in Swindon and runs the QOF Database website
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